A list of the most recent deficiencies for Westminster Oaks. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-09-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-09-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-07-26 | 2023-09-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-09-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-07 | 2022-08-05 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-13 | 2022-06-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-13 | 2022-02-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-13 | 2022-02-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-08 | 2021-05-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-08 | 2021-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-04-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-08 | 2021-04-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-08 | 2021-04-15 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-01-05 | 2021-04-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-01-08 | 2021-02-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-08 | 2021-02-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-01-08 | 2021-02-08 | N |
